EMK PREHOSPITAL/EMERGENCY MEDICINE/CRITICAL CARE CME SEMINARS

EMK Internal CME

4 July 2023
th

Pre-Eclampsia and Eclampsia

By: S. Mori
Registrar
OUTLINE
Definition: Classical Thinking
• Preeclampsia – A pregnancy-specific disorder of multisystem
involvement characterized by new-onset hypertension after
20weeks gestation, proteinuria and oedema
Williams Obstetrics. 25th Ed. 2018

• Other pregnancy related HTN disorders include:

• Chronic Hypertension of any etiology
• Preeclampsia superimposed on chronic hypertension
• Gestational Hypertension
American College of Obstetrics and Gynaecology.2013
 Revised Pre-Eclampsia Definition:
• New-onset of hypertension (sys ≥ 140mmHg and/or diastolic
≥ 90mmHg) after 20 weeks of gestation with:
• Proteinuria and/or
• End-organ dysfunction:
• renal dysfunction,
• liver dysfunction,
• central nervous system disturbances,
• pulmonary edema, and
• thrombocytopenia
Magley, M. and Hinson, M.R. (2020). Eclampsia. (DOI: https://www.ncbi.nlm.nih.gov/books/NBK554392/.)
 Epidemiology

• Global estimates derived from approximately 39million pregnancies suggest

incidence of 4.6%
• Accounts for 63000 Maternal deaths in LMIC per annum

• Regional variations noted in incidence: 5% Whites, 9 % Hispanic, 11% in African-

American Women
(Williams Obstetrics. 25th Ed. 2018)
 Local Epidemiology
• Papua New Guinea has one of the highest MMR in the Asia-Pacific
Region
• 215 per 100 000 according to WHO
• Local Estimates vary (68-900 per 100 000)

• Leading causes of Maternal Deaths:

• Hemorrhage 30%
• Sepsis 25%
• Embolism 15%
• Eclampsia 14%
• Abortion 7%

https://doi.org/10.1080/26410397.2019.1686199
Risk Factors
Factor Relative Risk (95% CI)
Prior Preeclampsia 8.4 (7.1-9.9)
Chronic Hypertension 5.1 (4.0-6.5)
Diabetes 3.7 (3.1 -4.3)
Multifetal 2.9 (2.6-3.1)
BMI > 30kg/m2 2.8 (2.6-3.1)
Antiphospholipid Antibody 2.8 (2.6-3.1)
SLE 2.5 (1.0-6.3)
Prior Stillbirth 2.4 (1.7 -3.4)
Nulliparity 2.1 (1.9-2.4)
Chronic Kidney Disease 1.8 (1.5 – 2.1)

Adapted from Williams Obstetrics. 25th Ed. 2018

 Etiology of Preeclampsia
• The current understanding of preeclampsia considers 4 main etiologies:

i. Placentation Implantation with abnormal trophoblastic invasion of uterine vessels

ii. Immunological Maladaptive tolerance between maternal, paternal (placental)

and fetal tissues

iii. Maternal Maladaptation to cardiovascular or inflammatory changes of normal

pregnancy

iv. Genetic factors and Epigenetic Influences

Williams Obstetrics. 25th Ed. 2018

Abnormal Placentation Theory of
Preeclampsia

Williams Obstetrics. 25th Ed. 2018

Preeclampsia: Pathophysiology

SOURCE: Pre-eclampsia: pathophysiology and clinical implications | The BMJ

Pathophysiology: Primary Role of the
Placenta
• Factors disseminated into maternal circulation from the placenta are
thought to be key in development of PET

• Oxidative stress of placental syncytiotrophoblastic tissue releases a

complex mix of factors (proinflammatory cytokines, exosomes,
antiangiogenic proteins) disrupting endothelial function resulting in a
systemic inflammatory response.

• The pathophysiological changes observed in preeclampsia are the

consequences of endothelial dysfunction, vasospasm and ischemia.
Pathophysiological Alterations in PET
• Cardiovascular Effects:
• Increased Afterload due to
Increased Peripheral Resistance
• Diminished Preload
• Extravasation of intravascular fluid
into interstitial (extracellular)
space
• Altered Ventricular Function

Ventricular Fx in Pregnant Women – PET (Boxed) vs Non-PET (Striped).

Source: Williams Obstetrics. 25th Ed. 2018
Pathophysiological Alterations in PET
• Hematological Effects:
• Reduced blood volume with
hemoconcentration
• Maternal Thrombocytopenia
• Hemolysis
• Coagulation changes

Differences in blood volume increase during pregnancy: PET vs Non-

PET. Source: Williams Obstetrics. 25th Ed. 2018
Pathophysiological Alterations in PET
• Renal Effects:
• Reversible renal anatomical and
pathophysiological changes occur
in PET causing:
i. Renal Blood Flow
ii. Glomerular Filtration Rates
iii. Acute Kidney Injury (ATN)
• Clinical Parameters:
• Oliguria
• Proteinuria (>300mg/24hr,
30mg/dL or + on dipstick)
• Elevated Creatinine (>1mg/dL)
• Hyperuricemia
Williams Obstetrics. 25th Ed. 2018
Pathophysiological Alterations in PET
• Hepatic Effects: • Clinical Signs/Parameters:
• Periportal hemorrhage in liver • RUQ Pain (Severe Sign)
periphery with ischemia and • Elevated liver transaminase
edema -> Stretching of Glisson enzymes (ALT,AST)
Capsule

Williams Obstetrics. 25th Ed. 2018

Pathophysiological Alterations in PET
• Neurological Effects:
• Intracerebral Hemorrhage
(Cortical & Sub-cortical)
• Disruption of cerebral auto-
regulation of blood flow -> hyper-
perfusion and extravasation of
plasma and RBC through disrupted
endothelial junctions ->
perivascular edema
• Transtentorial Herniation
• Retinal Detachment
• Clinical Signs/Parameters:
• Headaches
• Visual Disturbances (Scotoma,
Blindness)
• Hyperreflexia and Clonus
• Convulsions (Eclampsia)
• Hemiplegia
• Coma
• Cognitive Disturbance
Williams Obstetrics. 25th Ed. 2018
Diagnosis of Preeclampsia
• Preeclampsia is diagnosed on the basis of:

• New Onset Hypertension (BP>140/90mmHg) past 20weeks gestation in a

previously normotensive woman

• Proteinuria (>300mg/24hr, or persistent urine protein 30mg/dL i.e. (+) on

dipstick for random protein

• Evidence of End-Organ Dysfunction

• PET is no longer considered under ‘mild’ or ‘severe’ forms.

Williams Obstetrics. 25th Ed. 2018

 ECLAMPSIA
• New onset of seizures in a woman with pre-existing preeclampsia

• Seizures: generalized tonic-clonic, 60-90s in duration followed by

post-ictal state

• Eclamptic seizures can occur:

• Antepartum, (20 weeks after gestation),
• Intrapartum, and
• Postpartum (high risk 48hrs post delivery).
Magley, M. and Hinson, M.R. (2020). Eclampsia. (DOI: https://www.ncbi.nlm.nih.gov/books/NBK554392/.)
Pre-Eclampsia Mx Considerations
• Expectant vs Hastened Delivery

• Neuro-prophylaxis for Convulsions

• Antihypertensive/Blood Pressure Control

• Delivery of Healthy Baby

MX: Expectant vs Hastened Delivery
• Decision influenced by:

• Symptom progression (i.e. worsening)

• Evidence of end-organ dysfunction (e.g. deranged LFTs, RFTs, thrombocytopenia)

• Maternal-Fetal Compromise

• Early vs Late Onset PET

• NOTE: Definitive Mx of PET (Eclampsia) is delivery of the placenta

Pre-eclampsia: pathophysiology and clinical implications | The BMJ

MX: Neuroprophylaxis - MgSO4 Regimen
 MX: Antihypertensive Therapy
• ACOG recommends anti-HTN Rx in pregnant women with Sys ≥ 160mmHg
and or Dia ≥ 110mmHg

• 1st-line RX:

• Labetolol 20mg IV increased to 40-80mg

• Nifedipine 10mg PO initial increased to 20mg

• Hydralazine 5-10mg IV repeated after 20mins if sys ≥ 160mmHg and or dia ≥

110mmHg.
Magley, M. and Hinson, M.R. (2020). Eclampsia. (DOI: https://www.ncbi.nlm.nih.gov/books/NBK554392/.)
Eclampsia: The Fitting Patient
• A,B,Cs! Always!

• Lay patient left lateral, clear airway with suctioning

• Airway Maneuvers +/- Airway Adjuncts +/- Intubation

• MgSO4 drug of choice for eclamptic fits (See previous MgSO 4 protocol)

• Benzodiazepines and barbiturates in refractory fitting

• Levetiracetam and valproic acid in pregnant eclamptic patients with myasthenia gravis

• HASTENED DELIVERY!
Other Considerations
• Corticosteroids in fetus <34weeks to promote fetal
lung maturation

• Fluid Restriction and Diuretics in Pulmonary Edema

REFERENCES
• Williams Obstetrics.25th Ed. 2018
• Gianna Robbers , Joshua P. Vogel , Glen Mola , John Bolgna & Caroline S. E.Homer (2019) Maternal and
newborn health indicators in Papua New Guinea – 2008–2018, Sexual and Reproductive Health Matters,
27:1, 52-68,
• Graham J Burton, Christopher W Redman, James M Roberts, Ashley Moffett: Pre-Eclampsia:
Pathophysiology and Implications.BMJ 2019;366:l2381.doi: 10.1136/bmj.l2381
• Magley, M. and Hinson, M.R. (2020). Eclampsia. [online] PubMed. Available at:
https://www.ncbi.nlm.nih.gov/books/NBK554392/.